Chapter 6: Patient Selection

In this chapter

The SPNS Buprenorphine Initiative grantees faced many of the same barriers to care delivery and treatment implementation.

Polydrug Use and Mental Illness

Polydrug use and mental illness are prevalent among opioid-using individuals. A variety of tools and approaches need to be considered for selecting--and preparing-- patients for MAT with buprenorphine. Grantees used the Addiction Severity Index (ASI)-Lite, a validated selfreport measure used to assess frequency--and severity--of drug and alcohol use, along with associated psychosocial impairment.64,94,95

ASI-Lite was given at baseline (lifetime and past 30 days) and at each followup interval (past 30 days).64Information collected on the form included use about opioids (including heroin, nonprescribed methadone, and nonmedical use of pain medications), cocaine, methamphetamines, alcohol, and sedatives/barbiturates (e.g., benzodiazepines).64

Alcohol Use Disorders Identification Test (AUDIT)4 was used to screen for alcohol use and is included in SAMHSA's list of helpful addictionscreening instruments. SAMHSA also includes the Subjective Opiate Withdrawal Scale; Drug Abuse Screening Test (DAST-10); Clinical Institute Narcotic Assessment Scale for Withdrawal (CINA); CAGE Adapted to Include Drugs (CAGE-AID); Narcotic Withdrawal Scale; CAGE; Michigan Alcohol Screening Test (MAST); and Short Michigan Alcohol Screening Test (SMAST) as potential screening instruments. All of these can be accessed in Appendix B of the Guidelines.53

Patients using cocaine before initiating Suboxone were found to be less engaged in treatment and less likely to be retained in treatment, with fewer weeks of continuous opioid-free toxicology tests.99

SPNS project grantees used a harm-reduction approach to addressing substance use. In the case of polydrug use, some clients were allowed to enroll in the SPNS Buprenorphine Initiative if other substance use did not require acute intervention. These unique cases were reviewed on a weekly basis. In addition, increased frequency of counseling, 12-step meetings, and referral for an addiction psychiatry consult were recommended. For patients with severe polysubstance use, physicians should evaluate if buprenorphine is truly the best MAT option available or whether methadone or inpatient treatment may be preferable.

“Address the full spectrum of patients' substance abuse issues, recognize that addressing all issues will be a long-term endeavor, and individually tailor treatment plans to address polysubstance use over time.”100

Jails and Incarceration

The intersection of illicit substance use and incarceration is well documented. Some SPNS grantees work with their local jails to coordinate entry into HIV care services. Building on these relationships, a similar protocol was adopted for buprenoprhine. As one grantee describes,

“Many clients seeking buprenorphine treatment were facing legal issues that can complicate induction and maintenance therapy. When the substance abuse counselor first met each patient to discuss buprenorphine, she asked whether he or she had any impending court dates or sentencings. This information helped shape< the patients' treatment plan for timing induction before or after a jail sentence. Scheduling an appointment with the substance abuse/medical team immediately following release from jail (preferably the same day) can help patients maintain the sobriety typically attained while incarcerated.”101

Pregnancy

The amount of information on pregnant women on buprenoprhine is scarce. Pregnancy was included as an exclusion criterion in the SPNS Buprenorphine Initiative. For female patients undergoing MAT with buprenoprhine, providers should evaluate safe sex practices to prevent pregnancy. Should patients become pregnant during the course of buprenorphine treatment physicians should weigh all the risks to reach a conclusive decision.53 (See also Chapter 5, "Special Populations," of the SAMHSA guidelines.

Costs and Reimbursement

As Medicaid formularies vary from State to State, implementation of a buprenorphine treatment program must therefore take Medicaid's regulatory constraints into account.

Currently, there is no fee-for-service coverage of buprenorphine prescribed in outpatient settings. Buprenorphine may be covered in Medicare-certified programs or facilities for inpatient or emergency treatment; however, there are many variables. To read more about this, visit: The CSAT Buprenorphine Information Center Frequently Asked Questions page.

ADAP formularies vary by State. Some SPNS grantees were able to work with their State ADAP administrators and have Suboxone added to the formulary. This may not be true for all States and may be dependent on demand and resources.85

HIV care and substance abuse treatment care have often been reimbursed through separate funding streams. Coordinating reimbursement for these services may require a little additional time, as reimbursement is not always the same for HIV services as for substance abuse services, even if both are being submitted to the same payor.102

The University of California, San Francisco grantee found in the SPNS study that the approximate cost for a patient without an outside payor is about $10 a day.103 Costs may vary based on patient dose, and coverage by public and private payors for medication. Buprenorphine/naloxone medication can vary, typically from $4 to $19 per day.

Median labor and overhead costs of providing services for integrated care using national labor rates was $136 per patient month; using local labor rates, the median was $113. Toxicology analysis varied across the SPNS sites, with the median monthly cost being $8.102

Conclusion

Successful implementation of buprenorphine treatment into HIV primary care settings requires meeting patients where they are; offering nonjudgmental, culturally competent care services; addressing the mental health and social support needs of patients; and securing buy-in from necessary parties. The inclusion of substance abuse treatment under the umbrella of comprehensive HIV care offers an incredible opportunity to better serve people living with HIV/AIDS--the goal of the Ryan White HIV/AIDS Program.

HRSA continues this commitment through the development of a buprenorphine monograph, help desk, email list, and forthcoming educational Webinars.

The SPNS Buprenorphine Initiative grantees are testament that this melding of services is not only feasible but effective, too!

As one grantee summarized,

“Is it worth it? Absolutely. First and foremost, it expanded our capacity to take care of folks who were previously on the margins of engaging in health care. . . . it also had this spill-over effect of raising our awareness of addiction issues in general.”104

In the end, this work resulted in healthier patients, successful recovery, improved HIV and other health outcomes, and a clinic staff that realized not only was integrating buprenorphine easier than they thought, but more effective as well. So, what are you waiting for?